Wide QRS Complex Tachycardia Research Articles

R-wave peak time at DII: A new criterion for differentiating between wide complex QRS tachycardias

Differential diagnosis of wide QRS complex tachycardias using the 12-lead ECG may be difficult in many clinical settings. The purpose of this study was to determine the value of ECG lead II, specifically, the duration at its beginning, defined as R-wave peak time (RWPT), in differentiating ventricular tachycardia (VT) from supraventricular tachycardia (SVT) in patients with wide QRS complex tachycardia. Two hundred eighteen ECGs showing wide QRS complex tachycardias were evaluated. Two cardiologists blinded to the diagnosis measured RWPT duration at lead II (from the isoelectric line to the point of first change in polarity), and results between VT and SVT were compared, with the findings of electrophysiologic study used as the gold standard. One hundred sixty-three VTs had a significantly longer RWPT at DII (76.7 +/- 21.7 ms vs 26.8 +/- 9.5 ms in 55 SVT, P = .00001). Receiver operating characteristic curve identified RWPT > or =50 ms at lead II as having greater specificity and sensitivity in discriminating VT from SVT. Area under the curve was 0.97 (95% confidence interval 0.95-0.99), positive likelihood ratio was 34.8, and kappa coefficient (kappa) was 0.86. Bivariate analysis identified higher age in VT patients (60.7 vs 50.1 years, P < or =.01) and wider QRS complex duration at lead II in VT patients (169.4 vs 128.3 ms, P <.0001). QRS width at DII was not superior to RWPT in diagnosing VT. RWPT > or =50 ms at DII is a simple and highly sensitive criterion that discriminates VT from SVT in patients with wide QRS complex tachycardia.

207 Incidence and clinical significance of the asssociation of paroxysmal supraventricular and ventricular tachycardia

Fine-QRS complex tachycardia alternating with wide-QRS complex tachycardia can lead to an erroneous diagnosis of paroxysmal supraventricular tachycardia (SVT) with or without aberrancy. The purpose of the study was to evaluate the incidence and the significance of the association of SVT and ventricular tachycardia (VT) in the same patient. 898 patients aged from 11 to 88 years were consecutively admitted for a sustained VT; 818 patients had associated heart disease (history of myocardial infarction 374, idiopathic dilated cardiomyopathy 69, arrhythmogenic right ventricular dysplasia 86, miscellaneous 289) and 80 had no apparent heart disease. Electrophysiological study including programmed atrial and ventricular stimulation, 2D cardiac echocardiography, coronary angiography in patients older than 40 years, right ventricular angiography and cardiac RMI since 2002, were performed in these patients. Fifteen patients presented (2%) with either SVT or VT. All SVT's were related to an atrioventricular node reentrant tachycardia (AVNRT). The association of SVT and VT was significantly more frequent in patients without heart disease and with verapamil-sensitive VT (n=6/80, 7.5%)(<0.001), arrhythmogenic heart disease (n=4/86, 5%)(0.05) than in those with myocardial infarction (n=4/374, 0.1%) or dilated cardiomyopathy (n=0). Among 692 patients with AVNRT, 39 had associated heart disease and only 5 have both tachycardias. Radiofrequency ablation of AVNRT performed in all patients did not change the recurrence of VT which required ablation in 3 patients and the implantation of antitachycardia device with defibrillator in 2 patients. The association of SVT and VT is rare in patients with heart disease except in those with arrhythmogenic right ventricular dysplasia. The association is more frequent in patients without heart disease diagnosis and could be underestimated; fine QRS complex tachycardia alternating with wide QRS complex tachycardia leads generally to the erroneous diagnosis of SVT with or without aberrancy.

Ventricular Tachycardia With Hemodynamic Instability Refractory to Cardioversion: A Case Report

Accurate diagnosis of wide QRS complex tachycardia is difficult in emergent situations. According to the Advanced Cardiac Life Support (ACLS) tachycardia algorithm of the American Heart Association, immediate synchronized cardioversion should be applied to patients with wide QRS tachycardia with any evidence of hemodynamic instability. However, this may not be appropriate in all patients, especially those with idiopathic left ventricular tachycardia. In our patient, repetitively synchronized cardioversion failed to convert the arrhythmia. It is important for emergency physicians to recognize the electrocardiographic features of idiopathic left ventricular tachycardia and to manage these patients appropriately.

Adenosine for wide-complex tachycardia: Efficacy and safety*

: To determine whether adenosine is useful and safe as a diagnostic and therapeutic agent for patients with undifferentiated wide QRS complex tachycardia. The etiology of sustained monomorphic wide QRS complex tachycardia is often uncertain acutely. : A retrospective observational study. : Treatment associated with emergency visits at nine urban hospitals. : Consecutive patients treated with adenosine for regular wide QRS complex tachycardia between 1991 and 2006. : Treatment with adenosine infusion. : Measured outcomes included rhythm response to adenosine, if any, and all adverse effects. A positive response was defined as an observed change in rhythm including temporary atrioventricular conduction block or tachycardia termination. A primary adverse event was defined as emergent electrical or medical therapy instituted in response to an adverse adenosine effect. A rhythm diagnosis was made in each case. The characteristics of adenosine administration as a test for a supraventricular as opposed to ventricular tachycardia were determined, and the adverse event rates were calculated. A total of 197 patients were included: 104 (90%) of 116 (95% confidence interval, 83%-95%) and two (2%) of 81 (95% confidence interval, 0.3%-9%) supraventricular tachycardia and ventricular tachycardia patients demonstrated a response to adenosine, respectively. The odds of supraventricular tachycardia increased by a factor of 36 (95% confidence interval, 9-143) after a positive response to adenosine. The odds of ventricular tachycardia increased by a factor of 9 (95% confidence interval, 6-16) when there was no response to adenosine. The rate of primary adverse events for patients with supraventricular tachycardia and ventricular tachycardia was 0 (0%) of 116 (95% confidence interval, 0%-3%) and 0 (0%) of 81 (95% confidence interval, 0%-4%), respectively. : Adenosine is useful and safe as a diagnostic and therapeutic agent for patients with regular wide QRS complex tachycardia.

Wide QRS complex tachycardia with alternating QRS complexes during cardiac resynchronization therapy: What is the mechanism?

Wide QRS complex tachycardia with alternating QRS complexes during cardiac resynchronization therapy: What is the mechanism?

The Lewis Lead

An 80-year-old man was admitted to our hospital because of complaints of dizziness and palpitations. His medical history revealed an anteroseptal myocardial infarction 26 years earlier. The patient was hemodynamically stable with a blood pressure of 95/60 mm Hg and a heart rate of 120 bpm. The ECG (Figure 1A) showed a wide QRS complex tachycardia, 120 bpm. The electric axis was northwest. From the tracing, atrioventricular dissociation was suggested but not readily apparent. QRS morphology in leads V1 (qR) and V6 (R/S <1) was consistent with a diagnosis …

Wide QRS tachycardia complexes narrower than baseline: an uncommon electrocardiographic clue for ventricular tachycardia

A 69-year-old man was referred to our institution for an out of hospital episode of initially well-tolerated sustained wide QRS complex tachycardia reverted by direct-current cardioversion. The patient had a long history of ischaemic heart disease, including a remote anterior myocardial infarction and severe left ventricular dysfunction associated with an anteroseptal aneurysm. He was taking aspirin, atenolol, ACE inhibitors, and statins. The resting ECG showed normal sinus …

Rate-related changes in QRS morphology in patients with fixed bundle branch block: implications for differential diagnosis of wide QRS complex tachycardia

To analyse QRS morphology in response to rapid atrial pacing (RAP) and supraventricular tachycardia (SVT) in patients with pre-existing bundle branch block (BBB). We prospectively studied 59 patients in sinus rhythm (SR), with QRS > or = 120 ms, and no pre-excitation. Trains of RAP were introduced at increasing rates until atrioventricular block. QRS during SR and last QRS complex of each RAP train were compared on the 12-leads. Previously described criteria for minor and major configuration differences were used to identify QRS changes. During RAP minor QRS changes were seen in 22 (37%) and major changes in 23 (39%) subjects. One patient showed major axis shifts and no one showed a change to the contralateral BBB pattern. QRS changes were significantly and independently related to RAP rate and type of BBB (more frequent if right-BBB). Of 14 subjects (24%) with SVT, 13 displayed the same QRS changes during RAP. In patients with organic BBB, important changes in QRS morphology, except for a change in the contralateral BBB, can appear during RAP and SVT. Thus, in these patients, a change in QRS morphology during tachycardia does not necessarily imply that it is ventricular tachycardia.

Standardizing electrocardiographic leads: introduction to a symposium

Since Einthoven introduced the string galvanometer in 1902, electrocardiography has evolved as one of the most widely used tests in the practice of medicine. The routine 12-lead electrocardiogram (ECG), comprising limb leads, augmented frontal plane leads, and precordial leads, has been standardized for half a century. Routine electrocardiography is a fundamental tool for establishing cardiac rhythm and for the diagnosis of acute and chronic diseases of the heart. Comparison of serial ECGs is important in clinical decision making, and this requires technical consistency to minimize nonbiologic variability. Important elements of technical consistency include choice of leads and accuracy of electrode placement. To identify Q waves of prior myocardial infarction and to quantify QRS amplitudes to diagnose ventricular hypertrophy, proper lead placement of the standard electrodes can be extremely important. Electrode placement can have a profound effect on the quantitative variability of serial ECG findings. For example, to evaluate changing ST-segment deviation in patients with acute coronary syndromes, consistent electrode placement is essential. For most rhythm diagnoses, precise lead placement is less critical, but electrode placement is important when QRS morphology is used to determine whether a wide QRS complex tachycardia is ventricular tachycardia or supraventricular tachycardia with aberrancy or bundle branch block. Before the modern era of acute coronary care and hospital-based monitoring and telemetry, nearly all ECGs recorded in the course of practice used a standard 12-lead electrode array that evolved by empirical consensus in the 1930s and 1940s. Early exercise tests conducted with the master 2-step protocol used supine limb lead tracings recorded before and after effort, but exceptions began to occur in the last third of the 20th century when bipolar torso electrodes were introduced to allow activity-compatible

Negative precordial concordance: Is it a supraventricular tachycardia or ventricular tachycardia?

A 49-year-old man with a wide QRS complex tachycardia was referred for catheter ablation. Twelve-lead ECG revealed a regular wide QRS complex tachycardia with a left bundle branch block (LBBB) pattern (Figure 1). Is this a supraventricular tachycardia or ventricular tachycardia?

A case of imipramine induced toxicity with Brugada electrocardiographic pattern in a toddler

Imipramine, a tricyclic antidepressant (TCA), is used for the treatment of non-polar depression and nocturnal enuresis in children in whom an organic pathology has been excluded, anxiety disorders, and neuropathic pain. Clinical toxicity following the treatment of TCAs, including imipramine, is well known. The anticholinergic effects initially present include a dry mouth, ileus, dilated pupils, urinary retention, and mild sinus tachycardia. The central nervous system toxicity includes delirium, agitation, restlessness, hallucinations, convulsions, and CNS depression or coma. However, the most life-threatening toxicity remains the development of cardiac dysrhythmias. Conduction delays such as QRS and corrected QT prolongation, wide QRS complex tachycardia, and the Brugada electrocardiographic pattern have been reported. Sodium bicarbonate decreases QRS widening and suppresses dysrhythmias by providing excess sodium to reverse the TCA-induced sodium-channel blockade and possibly by binding directly to the myocardium. There are no pediatric case reports on imipramine or other TCA associated toxicity in Korea. Here, we describe a patient who presented with convulsions, tachycardia with a wide QRS complex, a Brugada electrocardiographic pattern, and anuresis associated with an accidental overdose of imipramine and the outcome of treatment with sodium bicarbonate.

Wide QRS-complex tachycardia with variable VA-conduction: what is the mechanism?

We describe the case of a 16-year-old woman with a surgically corrected tetralogy of Fallot presenting with recurrent wide-QRS-complex tachycardia. The tachycardia could be induced and terminated with ventricular stimulation only. QRS morphology during sinus rhythm and tachycardia was identical and variable VA-conduction was observed. Mapping of the tachycardia showed that variations of HH intervals preceded VV intervals. Therefore, a mechanism involving re-entry within the bundle branches was suggested. However, detailed mapping showed cranial to caudal depolarization of the His bundle, leading to the diagnosis of atrioventricular node re-entrant tachycardia. The tachycardia was abolished by radiofrequency catheter ablation of the slow AV nodal pathway. We conclude that variable VA conduction can occur in patients with atrioventricular node re-entrant tachycardia. The atrial tissue is not always an integral part of the re-entrant circuit.

Entrainment Mapping of a Concealed Nodoventricular Accessory Pathway in a Man with Complete Heart Block and Tachycardia‐Induced Cardiomyopathy

True nodoventricular (NV) accessory connections, as originally described by Mahaim, are rare entities, with the majority of previously reported cases now recognized as being due to decremental atriofascicular pathways. Here, we present a patient with incessant narrow and wide QRS complex tachycardia occurring in the setting of prior complete heart block. Entrainment mapping proved useful in diagnosing orthodromic reentry utilizing a concealed right septal NV pathway. The patient was successfully treated with radiofrequency ablation, resulting in a marked improvement in left ventricular function.

New algorithm using only lead aVR for differential diagnosis of wide QRS complex tachycardia

We recently reported an ECG algorithm for differential diagnosis of regular wide QRS complex tachycardias that was superior to the Brugada algorithm. The purpose of this study was to further simplify the algorithm by omitting the complicated morphologic criteria and restricting the analysis to lead aVR. In this study, 483 wide QRS complex tachycardias [351 ventricular tachycardias (VTs), 112 supraventricular tachycardias (SVTs), 20 preexcited tachycardias] from 313 patients with proven diagnoses were prospectively analyzed by two of the authors blinded to the diagnosis. Lead aVR was analyzed for (1) presence of an initial R wave, (2) width of an initial r or q wave >40 ms, (3) notching on the initial downstroke of a predominantly negative QRS complex, and (4) ventricular activation-velocity ratio (v(i)/v(t)), the vertical excursion (in millivolts) recorded during the initial (v(i)) and terminal (v(t)) 40 ms of the QRS complex. When any of criteria 1 to 3 was present, VT was diagnosed; when absent, the next criterion was analyzed. In step 4, v(i)/v(t) >1 suggested SVT, and v(i)/v(t) < or =1 suggested VT. The accuracy of the new aVR algorithm and our previous algorithm was superior to that of the Brugada algorithm (P = .002 and P = .007, respectively). The aVR algorithm and our previous algorithm had greater sensitivity (P <.001 and P = .001, respectively) and negative predictive value for diagnosing VT and greater specificity (P <.001 and P = .001, respectively) and positive predictive value for diagnosing SVT compared with the Brugada criteria. The simplified aVR algorithm classified wide QRS complex tachycardias with the same accuracy as standard criteria and our previous algorithm and was superior to the Brugada algorithm.

Can a new algorithm improve diagnostic accuracy in wide QRS complex tachycardia?

Can a new algorithm improve diagnostic accuracy in wide QRS complex tachycardia?

A Wide QRS Complex Tachycardia with Different Initiation Patterns: What is the Mechanism?

A 47-year-old man with palpitations underwent electrophysiologic testing (EPS). Burst atrial pacing while infusing isoproterenol induced non-reproducible wide QRS tachycardias with an unusual pattern of an H-A-V activation with the same tachycardia cycle length and two different initiation patterns. The tachycardia had the earliest atrial activation at the His bundle region. No dual atrioventricular (AV) nodal physiology was demonstrated by programmed atrial stimulation. Though a definite diagnosis of AV nodal reentrant tachycardia was not obtained, slow pathway ablation was performed in order to avoid inadvertent AV block as a complication. Thereafter, no tachycardias were induced by repeat burst atrial pacing.

Wolff-Parkinson-White Syndrome and Atrial Fibrillation in a Patient With a Coronary Sinus Diverticulum

A 51-year-old woman without known cardiac disease presented with an irregular wide QRS-complex tachycardia (Figure 1). After electrical cardioversion, the 12-lead surface ECG revealed sinus rhythm with ventricular preexcitation and negative delta waves in leads II, III, and aVF, indicating Wolff-Parkinson-White syndrome with a …

Akuttherapie lebensbedrohlicher tachykarder Rhythmusstörungen

Life-threatening supraventricular tachyarrhythmias include atrial fibrillation, atrial flutter, AV-nodal reentrant tachycardia with rapid ventricular response and preexcitation syndromes combined with atrial fibrillation. Ventricular tachyarrhythmias still remain one of the leading causes of death; these arrhythmias include monomorphic and polymorphic ventricular tachycardia, torsade de pointes tachycardia, ventricular fibrillation and ventricular flutter. In all patients with tachycardias, an attempt should be made to differentiate between narrow (QRS duration < 0.12 s) or wide QRS complex (QRS duration ≥ 0.12 s) tachycardias. In the assessment of patients (pts) with supraventricular/ventricular tachyarrhythmias, attention should be given to identify whether the tachycardia is associated with worsening angina or low cardiac output. In pts with narrow QRS complex tachycardias or pts with atrial fibrillation and preexcitation syndromes immediate synchronized cardioversion should be performed if signs or symptoms of instability (hypotension, evidence of end-organ dysfunction, worsening angina) exist. In pts with a stable hemodynamic situation, vagal maneuvers, adenosine or calcium channel blockers can be used. Management of atrial flutter usually centers on cardioversion or rapid atrial pacing to normal sinus rhythm. In the treatment of patients with deemed unstable ventricular tachycardia (VT), electrical cardioversion is the treatment of choice. In more stable patients, ajmaline is the preferred agent after myocardial infarction and lidocaine if myocardial ischemia is present. In pts with torsade de pointes tachycardias aggressive steps must be taken to prevent degeneration of this rhythm to ventricular fibrillation (VF). Magnesium sulfate has recently been demonstrated efficacious and is currently considered first-line drug therapy. Transcutaneous overdrive pacing should be attempted if magnesium is unsuccessful. The pt with pulseless VT or VF demands early electrical countershock.

FBI (Fast Broad Irregular)

HomeCirculationVol. 114, No. 24FBI (Fast Broad Irregular) Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBFBI (Fast Broad Irregular)A Case for the Secret Service? Sergio Richter, MD and Pedro Brugada, MD, PhD Sergio RichterSergio Richter From the Heart Rhythm Management Institute, Department of Cardiology, Free University of Brussels, Brussels, Belgium. Search for more papers by this author and Pedro BrugadaPedro Brugada From the Heart Rhythm Management Institute, Department of Cardiology, Free University of Brussels, Brussels, Belgium. Search for more papers by this author Originally published12 Dec 2006https://doi.org/10.1161/CIRCULATIONAHA.106.641746Circulation. 2006;114:e638–e639A 34-year-old man without a medical history of cardiac disease presented to our emergency room with fast and irregular palpitations. An instantaneously recorded surface ECG revealed the diagnosis (Figure). The tracing showed an irregular, wide QRS-complex tachycardia with right bundle-branch block, right superior axis deviation, and short RR intervals varying from 160 to 340 ms. The widths of the right bundle-branch block–shaped QRS complexes varied in response to changes in ventricular cycle length. A narrow QRS complex with normal axis was observed (Figure, asterisk), indicating a normally conducted capture beat. Download figureDownload PowerPointTwelve-lead ECG during fast, broad, and irregular (FBI) tachycardia. Preexcited atrial fibrillation with rapid anterograde conduction over a left posterolateral bypass tract is present. Note the normal, narrow QRS complex (asterisk) among the irregularly irregular preexcited ventricular complexes and the varying degrees of preexcitation depending on variation in ventricular cycle length (the concertina phenomenon). The shortest RR interval is 160 ms.This grossly irregular, rapid right bundle-branch block tachycardia represented preexcited atrial fibrillation (AF) with anterograde conduction over a left posterolateral accessory pathway, leading to irregularly irregular preexcited ventricular complexes with varying degrees of preexcitation. The shortest RR interval during preexcited AF was 160 ms, indicating a short anterograde refractory period of the accessory pathway and an increased risk for the development of ventricular fibrillation and sudden death.The differential diagnosis of preexcited AF includes ventricular tachycardia and atrial fibrillation with aberrancy. The presence of an apparent fusion and capture beat could lead one to the diagnosis of ventricular tachycardia, because these findings are considered diagnostic for ventricular tachycardia. Morphologically speaking, the tachycardia is ventricular in origin. Nevertheless, the marked cycle-length variation of more than 100% strongly argues against ventricular tachycardia and instead favors preexcited AF as the underlying arrhythmia mechanism. The right superior axis deviation and the fact that longer RR intervals lead to more fully preexcited QRS complexes compared with shorter RR cycles (the concertina phenomenon) virtually exclude AF with solely aberrant conduction.Preexcited atrial fibrillation with rapid ventricular response reveals a typical electrocardiographic pattern that is often diagnostic at first glance. Because of its characteristic ECG features (fast, broad, and irregular), this tachyarrhythmia has been named FBI tachycardia. This potentially life-threatening clinical condition is obviously a case for the emergency rather than the secret service.DisclosuresNone.FootnotesCorrespondence to Sergio Richter, MD, Heart Rhythm Management Institute, Department of Cardiology, Free University of Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium. E-mail [email protected] Previous Back to top Next FiguresReferencesRelatedDetailsCited By Littmann L, Olson E and Gibbs M (2019) Initial evaluation and management of wide-complex tachycardia: A simplified and practical approach, The American Journal of Emergency Medicine, 10.1016/j.ajem.2019.04.027, Online publication date: 1-Apr-2019. December 12, 2006Vol 114, Issue 24 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.106.641746PMID: 17159067 Originally publishedDecember 12, 2006 PDF download Advertisement SubjectsArrhythmiasElectrophysiology

Application of a new algorithm in the differential diagnosis of wide QRS complex tachycardia

The Brugada criteria proposed to distinguish between regular, monomorphic wide QRS complex tachycardias (WCT) caused by supraventricular (SVT) and ventricular tachycardia (VT) have been reported to have a better sensitivity and specificity than the traditional criteria. By incorporating two new criteria, a new, simplified algorithm was devised and compared with the Brugada criteria. A total of 453 WCTs (331 VTs, 105 SVTs, 17 pre-excited tachycardias) from 287 consecutive patients with a proven electrophysiological (EP) diagnosis were prospectively analysed by two of the authors blinded to the EP diagnosis. The following criteria were analysed: (i) presence of AV dissociation; (ii) presence of an initial R wave in lead aVR; (iii) whether the morphology of the WCT correspond to bundle branch or fascicular block; (iv) estimation of initial (v(i)) and terminal (v(t)) ventricular activation velocity ratio (v(i)/v(t)) by measuring the voltage change on the ECG tracing during the initial 40 ms (v(i)) and the terminal 40 ms (v(t)) of the same bi- or multiphasic QRS complex. A v(i)/v(t) >1 was suggestive of SVT and a v(i)/v(t) <or=1 of VT. An initial R wave in lead aVR suggested VT. The overall test accuracy of the new algorithm was superior (P = 0.006) to that of the Brugada criteria. The new algorithm had a greater sensitivity (P < 0.001) and (-) predictive value (NPV) for VT diagnosis, and specificity (P = 0.0471) and (+) predictive value (PPV) for SVT diagnosis than those of the Brugada criteria [both NPV for VT diagnosis and PPV for SVT diagnosis were: 83.5% (95% confidence interval = CI 75.9-91.1%) for the new vs. 65.2% (95% CI 56.5-73.9%) for the Brugada algorithms]. The new algorithm is a highly accurate tool for correctly diagnosing the cause of WCT ECGs.